STUDY DESIGN: A retrospective review of a consecutive series of patients with acute thoracolumbar burst fractures who were surgically treated with an anterior corpectomy and fusion with anterolateral Z-plate fixation. OBJECTIVES: To evaluate the clinical and radiographic success of the management of acute thoracolumbar burst fractures by corpectomy, structural grafting, and anterolateral internal fixation. SUMMARY OF BACKGROUND DATA: Burst fractures are frequently associated with instability or neurologic deficit. Modern surgical procedures for these fractures have been performed via both anterior and posterior approaches. Anterior surgical treatment allows direct decompression of the neural elements and correction of deformity. Newer anterior instrumentation devices, combined with a structural graft, allow a stable construct that may obviate a posterior procedure. An anterior procedure generally requires fusion of only two levels compared to posterior fusion, which generally requires more. METHODS: A retrospective review of a consecutive series of patients with thoracolumbar burst fractures treated with anterior surgery, strut graft, and fixation with a Z-plate was carried out. Fractures were considered acute if surgically treated within 30 days. Clinical and radiographic evaluation was performed on all 35 patients with acute thoracolumbar burst fractures. Surgical indications were incomplete neurologic deficit, segmental kyphotic deformity, or significant comminution. All patients with acute thoracolumbar burst fractures with spinal cord injury were treated with an intravenous steroid protocol and were operated on within 24 hours of admission unless medically precluded. Forty-six percent (16 of 35) of patients with acute thoracolumbar burst fractures presented with a neurologic deficit. RESULTS: All 16 patients with neurologic deficit demonstrated at least one Frankel grade improvement on final observation, with 11 (69%) patients demonstrating complete neurologic recovery. Thirty-three patients were treated with anterolateral instrumentation only. Twenty-nine of thirty patients demonstrated radiographic healing. Five were lost to follow-up observation. One patient required subsequent posterior fusion for increasing kyphotic deformity. There were no instances of hardware failure. Sagittal alignment was improved from a mean preoperative kyphosis of 18 degrees to 6 degrees at final follow-up observation. CONCLUSIONS: Anterior corpectomy, strut graft, and Z-plate fixation is an effective treatment for thoracolumbar burst fractures. It allows direct decompression of the spinal cord in the acute setting and was associated with a high rate of neurologic improvement, no instances of neurologic worsening in any case, and a low complication rate.